ANNEX A
SERIOUS REPORTABLE EVENT NOTIFICATION FORM
To:
Institution: __________
SRE Notification Officer
Standards & Quality Improvement Division
Ministry of Health
College of Medicine Building
16 College Road
Singapore 169854
Email: moh_sers@moh.gov.sg
Serial Number: 20___1/ ____2
Date of event occurrence:
___/ ___/ ___ (dd/mm/yy)
Date identified as SRE3:
___/ ___/ ___ (dd/mm/yy)
Case reported to the Coroner: Yes/No
Age of patient: _____
Gender: _____
Race: _____
Ward discipline/ Department: ______________
From:
Ward class: _____
Name:____________________
SRE Category (Refer to Table 1):
Designation: _______________
Tel: ______________________
Outcome of SRE: Death / Serious Injury / No Serious Injury4
E-mail: ___________________
1
Signature: ________________
Date: _____________
Refers to the calendar year in which the serious reportable event has occurred
2
This number is to be assigned by the institution to serialise all serious reportable events
that occurred during the calendar year.
3
The QAC that reviews the SRE shall notify the Standards & Quality Improvement
Division, Ministry of Health, of an SRE within 2 working days of the date of the event being
identified.
4
Indicate outcome of the event as of the report date
ANNEX A
SERIOUS REPORTABLE EVENT NOTIFICATION FORM
Please describe briefly below the above serious reportable event that has occurred [attach additional page(s) if necessary]:
Background/Relevant history:
Summary of Incident:
Patient outcome as of report date:
ANNEX A
SERIOUS REPORTABLE EVENT NOTIFICATION FORM
Table 1: SRE Categories
a) Surgical or Invasive Procedure Events
1. Surgery or other invasive procedure performed on the wrong body site
2. Surgery or other invasive procedure performed on the wrong patient
3. Wrong surgical or other invasive procedure performed on a patient
4. Unintended retention of a foreign object in a patient after surgery or other invasive procedure
5. Intraoperative or immediately post-operative/post-procedure death in an ASA1 Class 1 patient
b) Product or Medical Device Events
6. Patient death or serious injury associated with the use of contaminated drugs, medical devices or biologics provided by the
healthcare institution
7. Patient death or serious injury associated with the use or function of a medical device in patient care in which the device is used
or functions other than as intended
8. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare
institution
c) Patient Protection Events
9. Discharge or release of an infant, a child or any person who lacks capacity, as referred to in section 4(1) of the Mental Capacity
Act (Cap. 177A), other than an authorised person
10. Patient death or serious injury associated with patient abscondment (disappearance)
11. Patient suicide, attempted suicide or self-harm that results in serious injury, while being cared for in a healthcare institution
d) Environmental Events
12. Patient death or serious injury associated with an electric shock in the course of a patient care process in a healthcare institution
13. Any incident in which systems designated for oxygen or other gas to be delivered to a patient contain no gas, the wrong gas or
are contaminated by toxic substances
1
American Society of Anesthesiologists Physical Status Classification System
ANNEX A
SERIOUS REPORTABLE EVENT NOTIFICATION FORM
14. Patient death or serious injury associated with a burn incurred from any source in the course of a patient care process in a
healthcare institution
15. Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare
institution
e) Care Management Events
16. Patient harm, death or serious injury associated with a medication error (corresponding to Category E to I of Appendix 2, e.g.
errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of
administration). *Specify 16E, 16F, 16G, 16H or 16I according to the Category in ‘SRE Category’ above.
17. Patient death or serious injury or risk thereof associated with unsafe administration of blood and blood products
18. Transmission of diseases following blood transfusion, organ transplant or transplant of tissues
19. Maternal death or serious injury associated with pregnancy or delivery
20. Infant death or serious injury associated with labour or delivery in a low-risk pregnancy
21. Patient death or serious injury associated with a fall while being cared for in a healthcare institution
22. Stage 3, Stage 4 and unstageable pressure ulcer acquired after admission/presentation to a healthcare institution
23. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen
24. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology or radiology test results
25. Unexpected death or serious injury as a result of lack of treatment or delay in treatment which would have been prevented
otherwise
26. Unexpected death or serious injury as a result of medical intervention which would have been prevented otherwise
27. Any assisted human reproductive procedure which has or, may have, resulted in insemination of wrong gamete or transfer of
wrong embryo
f) Radiological Events
28. Radiological procedure performed (a) on the wrong patient, (b) on a pregnant patient
29. Radiopharmaceutical administered (a) to the wrong patient, (b) with a wrong type or dose
30. Radiation therapy delivered (a) to the wrong body site, (b) to the wrong patient, (c) with a wrong dose
31. Death or serious injury of a patient associated with the introduction of a metallic object into the MRI area